Introduction to Sleep Health

Good health and childhood development rely heavily on sleep throughout all developmental stages

Noelani's Story

Noelani, a 7-month baby girl is brought to the clinic by her parents who are concerned that she is not sleeping through the night. Dr Sofia Chavez is her regular pediatrician. Noelani is an only child. She lives with her parents who are in their early twenties. They live in a trailer which is close to her maternal grandparents' house.

Noelani’s parents report that she is not sleeping through the night. They are exhausted. She takes 5 short (1 hour) naps during the day. Noelani continues to breastfeed. She has started eating rice cereal in the morning.
Developmental History: Noelani sits by herself with minimal support, she babbles and is making repetitive sounds, cries only if she is hungry or sleepy, reaches for toys and tries to manipulate them, rolls, has a social smile and recognizes parents.

Expert Insights

BEARS Screening for Noelani

Noelani’s age is below what is recommended for the BEARS screening tool.

Bedtime Problems

Not Applicable.

Excessive Daytime Sleepiness

Not Applicable.


Not Applicable.

Regularity & Duration

Not Applicable.

Sleep-Disordered Breathing / Snoring

Not Applicable.

Noelani's Evaluation & Diagnosis

What evaluation & diagnostic protocol should the medical provider use to diagnose Noelani’s nighttime behaviors?
Check all that apply:

The evaluation and diagnostic protocol recommend for Noelani is:

  • Determine elements of the child’s sleep history
  • Perform a physical exam
  • Safe Sleep Practices
  • Feeding Habits

The history of a patient’s sleep problem is always of critical importance. This information helps to guide the physical exam, the ordering of further testing and/or referral to a specialist or reassurance.

Determine elements of Noelani's sleep history

Sleep History Case Specific Questions Noelani's Evaluation Results

What the child does at night

How long is Noelani sleeping at night? Why is she waking up?




Noelani goes to bed each night around 7:00 PM. She finishes breastfeeding 20 minutes before being put down in her crib. Noelani has never slept through the night. She wakes up 1-2 times a night to breastfeed.




Review timing of events at night (bedtime/waketime)

Is Noelani taking naps during the day?

She takes 2-3 naps during the day that last about 1-1.5 hours each.

Screen for other sleep issues (OSA, restless leg syndrome)

Is Noelani snoring or pausing in her breathing while sleeping?


Review of medications (antidepressants, seizure medications, and antihistamines all have impacts on sleep)

What medications is Noelani taking?

Multivitamin drop, 1 mL by mouth daily.

Assess for family history of sleep disorders



Perform a Physical Exam

Information to obtain includes: Case Evaluation Results

Growth parameters and physical exam, Weight is 15-50% (WHO Child Growth Standards)

Weight: 7 kg, 50th percentile
Weight-for-length: 15-50%
Length: 67 cm, 50th percentile
Head Circumference: 43cm, 50th percentile
Vital signs are within normal range.
General: alert in no acute distress
HEENT:  Anterior fontanelle is small, soft and flat; pupils are equal, round and reactive to light; nares are patent bilaterally; oropharynx is pink and moist, there is one front tooth on the lower gum, no cleft palate.
Remainder of exam is normal.

Safe Sleep Practices

Information to obtain includes: Case Evaluation Results

In what position is Noelani place in her crib? What bedding is used? Is her crib the only place she sleeps?

Noelani is placed on her back when she is being put down for a nap or at bedtime. There is a snug fitted sheet on the mattress. There are no bumper pads, loose bedding, or stuffed animals in the crib when she sleeps.

Noelani’s parents purchased a new crib that meets all current safety recommendations. It is set up in a nursery adjacent to the parent’s bedroom. When Noelani is placed in her crib for the night, she cries until her parents take her to their bed.

Feeding Habits

Information to obtain includes: Case Evaluation Results

What are Noelani's feeding habits?

Noelani breastfeeds for 20 minutes every 4-6 hours. She is also eating a few spoonfuls of rice cereal, or pureed baby foods a 2-3 times a day.

Options that are Not Recommended

Order Labs/Other Diagnostic Tests

Noelani’s development, growth, and physical exam are normal. No further testing is needed at this time.

Complete a Sleep Diary

Not applicable at this time.

Sleep Study

Sleep study is not indicated. A history of snoring, cyanosis, or apnea are common indications for a sleep study

Refer to a Specialist

Not indicated.

Red Flags

  • Enlarged head circumference, waking up in the middle of the night vomiting or inconsolable crying may be indicators of hydrocephalus and need further evaluation.
  • Overfeeding may lead to abdominal discomfort and disrupt sleep.
  • Loud snoring or apneic events need further evaluation.

When evaluating a child,
consider how other health care providers may also need to be involved.

Expert Insights:
Triggers for Safe Sleep

Evaluation & Diagnosis

Are Noelani’s sleep habits within normal ranges? What other factors might be contributing to her not yet sleeping through the night?
Check all that apply:

Noelani’s signs and symptoms are:

  • Normal for her age.

Noelani’s signs and symptoms are slightly above average but still within normal ranges. Most infants sleep through the night by 6 months but the range can be 3 - 12 months.

Noelani should be placed back into her own crib after she is attended to upon awakening in the night. Bed sharing is not recommended.

Noelani's Treatment & Referrals

Now it’s time to recommend treatment options for Noelani.
Check all that apply:

The following treatment strategies are recommended for Noelani:

  • Placement and use of crib
  • Parents offer of comfort
  • Feeding habits
  • Strategies for infant self comforting

Treatment Strategies for Self Comforting

  • Move Noelani’s crib into her parent’s bedroom and put her to sleep in it.
  • When she cries, Noelani’s parents should offer gentle comfort and place her back in her crib.
  • Increase soft food intake adding a feeding one hour before regular bedtime.
  • Provide a pacifier for Noelani during the night.

Noelani's Results:

Good news! At Noelani’s 9 month well child visit, her mom reports that Noelani sleeps 10 hours each night without awakening and takes three 45 minute naps since putting all of the suggestions to use.